Station 1: Respiratory Flashcards
key presentation points in respiratory examination
- respiratory distress
- cyanosis
- clubbing
- trachea/ apex
- pulmonary hypertension/ cor pulmonale
- rheumatological findings
- LN
what are the surface markings of the right lung anteriorly?
4th rib and above = upper lobe on the right
4th to 6th rib = middle lobe on the right
what are the surface markings of the left lung anteriorly?
6th rib and below on the left = left lower lobe
Asymmetrical chest wall with absent ribs
+ Lateral throacotomy scar
–> Thoracoplasty: possibly for TB treatment in the past
can get complications of respiratory failure, and BIPAP may be useful
lateral thoractomy scar with normal underlying lung on examination?
lung transplant
pleurectomy (e.g. for recurrent pneumothorax in Ehlers Danlos)
Bullectomy
lateral thoractomy scar with abnormal underlying lung?
- reduced breath sounds:
lobectomy
pneumonectomy (no breath sounds) - COPD with lung volume reduction surgery
- Lung transplant with complications
differential diagnoses for a patient with clubbing and crepitations?
bronchiectasis
pulmonary fibrosis
mitotic lung lesion (cancer)
abscess
what is bronchiectasis?
irreversible bronchial dilatation and bronchial wall thickening, secondary to repeated infection and chronic inflammation
clinical course of bronchiectasis?
chronic, progressive with recurrent infective exacerbations
symptoms of bronchiectasis?
productive purulent cough
dyspnoea
haemoptysis
signs of bronchiectasis?
coarse late inspiratory (and expiratory) crepitations
+/- expiratory wheeze
clubbing may be present
what is bronchiectasis sicca?
“dry” bronchiectasis
presents with recurrent haemoptysis and dry cough
affects the upper lobes therefore good drainage
usually from past history of granulomatous infection eg TB
what are the causes of focal bronchiectasis?
luminal blockage: foreign body, broncholith (focal calcified endobronchial material which usually follows erosion by a granulomatous peribronchial lymph node (e.g. TB))
arising from the wall: malignancy
extrinsic: enlarged LNs especially middle lobe from TB/fungi, displacement of airways post lobar resection
causes of diffuse bronchiectasis?
post-infectious:
- bacteria: pseudomonas, haemophilus, pertussis
- TB
- aspergillus: allergic bronchopulmonary aspergillosis
- virus: adenovirus, measles, influenza
congenital:
- cystic fibrosis
- alpha 1 antitrypsin deficiency
- kartagener’s syndrome of immotile cilia
- hypogammaglobulinaemia (primary immunodeficiency)
rheumatological:
- rheumatoid arthritis
- SLE
- sjogrens
others:
yellow nail syndrome
young’s syndrome
idiopathic (50%)
inflammatory bowel disease (UC, crohn’s)
congenital kyphoscoliosis
post infectious causes of diffuse bronchiectasis?
- bacteria: pseudomonas, haemophilus, pertussis
- TB
- aspergillus: allergic bronchopulmonary aspergillosis
- virus: adenovirus, measles, influenza
congenital conditions that may lead to diffuse bronchiectasis?
- cystic fibrosis
- alpha 1 antitrypsin deficiency
- kartagener’s syndrome of immotile cilia
- hypogammaglobulinaemia (primary immunodeficiency)
rheumatological conditions causing diffuse bronchiectasis?
- rheumatoid arthritis
- SLE
- sjogrens
other causes of diffuse bronchiectasis? (not 2’ infection/congenital/ rheumatological)
yellow nail syndrome (yellow nails, bronchiectasis, pleural effusion and lymphoedema)
young’s syndrome (bronchiectasis, rhinosinusitis, infertility due to obstructive azoospermia)
idiopathic (50%)
inflammatory bowel disease (UC, crohn’s)
congenital kyphoscoliosis
what is kartagener’s syndrome?
- a type of immotile ciliary syndrome -> retained secretions, recurrent infections and thus, bronchiectasis
comprises of:
- dextrocardia, situs inversus
- bronchiectasis, sinusitis, frontal sinus dysplasia, otitis media
- infertility
what is cystic fibrosis?
most commonly due to mutations to CFTR (CF transmembrane conductance regulator)
recurrent respiratory infections with pancreatic exocrine deficiency and short stature
- usually affects upper lobes
dx: sweat test: elevated sweat sodium and Cl concentrations, genetic testing
what kind of sputum in bronchiectasis?
3 layered sputum:
foamy upper layer,
mucous middle layer,
viscous purulent bottom layer
what are the differences between bronchiectasis vs COPD?
they may occur concomitantly
cause: cigarette smoke (COPD) vs infection/ genetics (bronchiectasis)
infection: usually secondary (COPD), primary (Bronchiectasis)
organisms: Strep pneumo, haemophilus (COPD) vs Haemophilus, pseudomonas (Bronchiectasis)
symptoms: dyspnoea, chronic cough (COPD) vs dyspnoea, productive cough, haemoptysis (bronchiectasis)
sputum: mucoid clear (COPD) vs 3 layered, purulent (bronchiectasis)
CXR: hyperlucency, hyperinflated (COPD), airway thickening, dilated airways (bronchiectasis)
what are the complications of bronchiectasis?
- pneumonia, collapse, pleural effusion, lung abscess, pneumothorax, haemoptysis
- brain asbcess
- sinusitis
- amyloidosis
ix of bronchiectasis?
to diagnose:
HRCT
CXR: helpful for diagnosis, extent and to assess for complications
Lung function tests: obstructive pattern
assess for complications:
FBC CRP
Sputum studies
CXR findings of bronchiectasis?
diagnosis:
- dilatated and thickened airways
- signet ring sign
- tram lines
extent and distribution
complications: pneumonia, abscess, pleural effusion
lung function tests in bronchiectasis?
- obstructive pattern with FEV1/FVC < 70%
- severity of obstruction based on FEV1
- some reversibility with beta agonist: 40% of patients have >15% improvement
HRCT findings in bronchiectasis?
diagnostic:
- dilation of airway lumen > 1.5x compared to nearby vessel
- signet ring sign (dilated bronchus with its pulmonary artery)
- lack of tapering of any airway toward the periphery with presence of bronchi within 1cm from the pleura
- Reid’s classification: cylindrical or tubular, varicose, saccular or cystic
- useful also in elucidating cause of focal bronchiectasis
assess distribution:
usually lower lobes
if upper lobes: suspect post TB, Cystic Fibrosis, ABPA
ir proximal bronchiectasis: ABPA
if middle lobe/lingula: M avium
complications
how may distribution of bronchiectasis on HRCT be suggestive of the underlying cause?
usually lower lobes
if upper lobes: suspect post TB, Cystic Fibrosis, ABPA
ir proximal bronchiectasis: ABPA
if middle lobe/lingula: M avium
characteristic auscultatory findings in pulmonary fibrosis?
late, fine inspiratory crepitations
velcro-like
quietens when the patient leans forwards
what are the causes of upper lobe pulmonary fibrosis?
BREAST CLAPS
Beryllium
Radiation
Extrinsic Allergic Alveolitis
Allergic bronchopulmonary aspergillosis
Silicosis
TB
Cystic fibrosis
Langerhans cell histiocytosis
Ankylosing spondylitis
Pneumoconiosis (Coal worker)
Sarcoidosis
what are the causes of lower lobe pulmonary fibrosis?
CARDI
Connective tissue disease: Systemic sclerosis
Asbestosis
Rheumatoid arthritis
Drugs: cytotoxics (e.g. MTX, azathioprine, bleomycin), phenyotin, amiodarone, hydralazine, nitrofurantoin, isoniazid, sulfasalaizine
Idiopathic pulmonary fibrosis (usual interstitial pneumonia)
what causes both upper and lower lobe interstitial lung disease?
- neurofibromatosis, tuberous sclerosis
- pulmonary haemorrhage syndromes
- extrinsic allergic alveolitis
- alveolar proteinosis (primary, secondary: silica, chronic infection, malignancy)
- lymphangiomyomatosis
how would you classify interstital lung disease?
ATS/ERS 2001:
diffuse parenchymal lung disease of known cause:
- collagen vascular disease: RA, SLE, dermatomyositis, systemic sclerosis
- occupational/environmental: asbestosis, silicosis, extrinsic allergic alveolitis
- drug related: cytotoxic, CNS, CVS, antbiotics, rheumatic
idiopathic:
IPF
other idiopathic interstitial pneumonias
granulomatous:
sarcoidosis
others:
LAM, histiocytosis
what are some other idiopathic interstitial pneumonias?
Desquamative interstitial pneumonitis
Acute interstitial pneumonia
Lymphocytic interstitial pneumonia
Nonspecific interstitial pneumonia
Cryptogenic organising pneumonia
Respiratory bronchiolitis
how would you diagnose idiopathic pulmonary fibrosis?
clinical, radiological, pathological
clinical:
- exclusion of other causes of ILD
- insidious onset of dyspnoea, >3 months, non productive cough
- typical physical findings
radiological: HRCT
pathological
investigations of pulmonary fibrosis?
HRCT to diagnose
CXR
Lung function tests: restrictive pattern
Bronchoalveolar lavage
Lung biopsy
Bloods: ABG, to rule out other causes
CXR in pulmonary fibrosis?
diagnostic:
bilateral basal reticulonodular shadows, peripheries, which advances upwards
honeycombing in advanced cases
loss of lung volume
extent and distribution
complications
lung function tests in pulmonary fibrosis?
restrictive pattern: reduced TLC or VC with increased FEV1/FVC ratio
severity of restriction based on total lung capacity
reduced transfer factor (impaired gas exchange)
HRCT scan findings for pulmonary fibrosis?
diagnosis:
- patchy reticular abnormalities
- focal ground glass
- architectural distortion
- volume loss
- subpleural cyst
- honeycombing
extent and severity: basal, peripheral, subpleural
complications
indication for bronchoscopy with lavage in diagnosis of pulmonary fibrosis?
- if predominantly lymphyocytes, usually responds to steroids and better prognosis (not UIP)
- predominantly neutrophils and eosinophils means poor prognosis = UIP
- if >20% eosinophils, to consider eosinophilic lung disease
management of intersitial lung disease/ pulmonary fibrosis?
education and counselling:
stop smoking
regular follow up and vaccinations
treat underlying cause if any
medications:
- trial of steroids: if responding, continue; if not: azathioprine or cyclophosphamide
- antifibrotics: pirfenidone
surgical: lung transplant
manage complications:
- cor pulmonale (diuretics for heart failure)
- polycythaemia (venesection if hct >55%)
- respiratory failure: oxygen therapy
- monitor for lung cancer
good prognostic factors for pulmonary fibrosis?
young age
female
short duration
ground glass appearance on CXR
minimal fibrosis on lung biopsy
what is the clinical course of patients with idiopathic pulmonary fibrosis?
gradual onset
progressive
median survival from time of diagnosis about 3 years
causes of death in pulmonary fibrosis?
cor pulmonale (right heart failure)
respiratory failure
pneumonia
lung carcinoma
what is hamman rich syndrome?
aka acute interstitial pneumonia
a rare idiopathic pulmonary disease that leads to fulminant respiratory failure (rapidly progressive, fatal variant of interstitial lung disease)
differential diagnoses for dullness on percussion of unilateral lower zone
- pleural thickening: old TB, prev empyema, mesothelioma, asbestosis, prev haemothorax
- basal consolidation
- lower lobe collapse
- raised hemidiaphragm:
(a) phrenic nerve palsy from cancer or phrenic nerve crush for old TB treatment with supraclavicular fossa scar
(B) hepatomegaly (right side) - malignancy
causes of a pleural effusion
group into transudative and exudative causes
causes of a transudative pleural effusion
- cardiac: congestive cardiac failure, constrictive pericarditis
- renal: nephrotic syndrome, hypoalbuminaemia, peritoneal dialysis
- chronic liver disease: hepatic hydrothorax
- myxoedema (hypothyroidism)
- atelectasis
causes of an exudative pleural effusion
malignancy: primary: bronchial or pleural, secondary: breast/pancreas/kidney/ovaries/lymphomas
infective: parapneumonic, TB
connective tissue: rheumatoid arthritis, SLE
PE
pancreatitis (left-sided)
drug induced: nitrofurantoin, bromocriptine
meig’s syndrome (ovarian fibroma, ascites and pleural effusion)
yellow nail syndrome
what is yellow nail syndrome?
triad of yellow nails/ onycholysis, pleural effusion/ bronchiectasis and lymphoedema
features of meig’s syndrome?
ovarian fibroma, ascites, pleural effusion
causes of haemothorax?
trauma
rupture of pleural adhesion containing blood vessel, carcinoma
causes of a chylothorax?
trauma or surgery to the thoracic duct
carcinoma or lymphoma affecting the thoracic duct
what is a chylothorax?
accumulation of lymphatic fluid within the pleural space
what is an empyema?
collection of pus in the pleural space
what is a parapneumonic effusion?
a pleural effusion that forms in the pleural space adjacent to a pneumonia
-> can become complicated parapneumonic effusion or empyema
causes of empyema?
pneumonia
abscess
bronchiectasis
TB
how to diagnose a pleural effusion?
Ultrasound
how to differentiate between an exudative and transudative effusion
Light’s criteria:
sensitive but not specific for exudates
- pleural fluid protein: serum protein > 0.5
- pleural fluid LDH: serum LDH > 0.6
- pleural fluid LDH >2/3 of ULN of serum LDH
if still suspecting transudate, can do SAAG (serum to pleural albumin gradient)
-> if >1.2g/dL, transudate
ix of pleural effusion
evaluate for underlying cause of the effusion
sputum studies: gram stain, culture, AFB smear/culture/ TB PCR, cytology
imaging:
CXR
US
CT
Diagnostic pleural tap +/- pleural biopsy
Blood investigations
indications for a diagnostic thoracocentesis?
> 10mm thick on a lateral decubitus film or USS
turbid appearance of pleural effusion
parapneumonic effusion, chylothorax
bloody looking pleural effusion: what values are significant
<1% insignificant
1-20%: malignancy, PE, trauma
>50% compared to peripheral Hct: haemothorax
neutrophil predominant pleural effusion
parapneumonic effusion
lymphocytes predominant pleural effusion
malignancy, TB, lymphoma, connective tissue disorders
eosinophilic pleural effusion
blood or air in the pleural space
drugs - nitrofurantoin, bromocriptine, dantrolene
churg-strauss (eGPA)
paragonimiasis
Asbestosis
what pleural fluid studies to send off from diagnostic thoracocentesis for pleural effusion?
FEME
pH
LDH
protein (Lights criteria)
glucose (<0.5 compared to serum: malignancy, TB, RA)
amylase (pancreatitis)
cultures: bacterial, TB, fungal
ADA
cytology
when must you order cxr post diagnostic tap?
when you suspect complications of pneumothorax:
- air aspirated
- patient develops chest pain/ SOB
- loss of tactile fremitus over superior part of the aspirated hemithorax
management of pleural effusion?
treat the underlying cause
treat symptoms: fever/ pain
SOB: therapeutic thoracocentesis
chest drain insertion: for complicated parapneumonic effusion, haemothorax
pleurodesis for malignant effusions
intrapleural fibrinolytics for loculated effusions
features of complicated parapneumonic effusion
turbid appearance (if gross pus -> empyema)
criteria:
pH < 7.20
Glucose < 3.3 mmol/l (60 mg/dl)
LDH > 1000
cultures could be positive
treatment of empyema
antibiotics
complete pleural fluid drainage
surgical decortication
causes of lung collapse?
intraluminal: foreign body, mucous plugging from asthma/ ABPA
luminal: endobronchial tumour, TB
extrinsic compression: enlarged LNs 2’ malignancy (primary/secondary), lymphomas, TB
what is brock’s syndrome?
right middle lobe (RML) atelectasis/ collapse by enlarged hilar lymphadenopathy compressing the right main bronchi
ix of lung collapse?
diagnosis of lung collapse:
cxr
ABG, FBC, biochemical profile
find underlying cause:
sputum studies: AFB smear/culture, Cytology
Bronchoscopy + biopsy
Staging for cancer: CT TAP, Bone scan/ PET CT
Physiological staging: lung function tests
management of lung collapse
treat underlying cause
management of lung malignancy causing lung collapse
acute scenario:
ABC approach
respiratory support if required
MDT approach: discussion at tumour board (radiology, med onco, resp, thoracic surgeons)
education and counselling, stop smoking
symptomatic treatment
treatment of actual cancer: surgery/ chemo/ radiotx
management of non small cell lung cancer?
refer to med onco / thoracic surgery
assessment for surgical resectability
- depends on staging: usually up to IIIA
- physiological staging: FEV1>1.5, transfer factor > 50%
chemotherapy: neoadjuvant/ adjuvant
radiotherapy: adjuvant/ palliative
palliative: radiotherapy, chemotherapy
management of small cell lung carcinoma
usually aggressive
chemotherapy initiated early
prophylactic cranial irradiation against brain mets
stereotactic radiotherapy/ surgery for limited vol disease sometimes offered
what FEV1 is required for pneumonectomy/ lobectomy
FEV1 >2-2.5L predicts better survival for pneumonectomy
lobectomy: usually FEV1>1.5L
how does patient with bronchogenic carcinoma present?
primary tumour: cough, sob, haemoptysis, pneumonia
mediastinal: SVCO, Horner’s, pleural effusion, phrenic nerve palsy, hoarseness of voice, T1 wasting, pericardial effusion
metastases: liver, bone, brain, skin, adrenals
paraneoplastic symptoms
systemic effects: LOW, LOA, fatigue
endocrine paraneoplastic syndromes assoc with lung cancer?
PTH related peptide (hypercalcaemia): SCC
SIADH: small cell
ACTH: Cushing’s (usually hypok met alkalosis)
Gynaecomastia
neurological paraneoplastic syndromes assoc with lung cancer?
subacute cerebellar degeneration
peripheral neuropathies (anti-Hu antibody)
Lambert-Eaton syndrome: anti-VGCC
paraneoplastic syndromes assoc with lung cancer affecting the skin?
migratory venous thrombophlebitis (trosseau’s sign)
acanthosis nigricans
dermatomyositis
paraneoplastic syndromes assoc with lung cancer affecting MSK/joints?
clubbing
HPOA: Hypertrophic pulmonary osteoarthropathy
features of SVCO?
plethoric facies
facial and UL oedema
conjunctival suffusion
fixed engorgement of neck veins
stridor
upper chest telangiectasia
signs of treatment: radiotherapy marks
underlying cause: lung carcinoma (esp small cell), lymphoma, mediastinal goitre
what are the causes of a consolidation?
infection:
pneumonia
abscess
TB
aspergilloma, cryptococcoma, hydatid cys
neoplastic/mass: carcinoma, lymphoma
pulmonary infarction
ix of consolidation?
CXR
ABG, bloods e.g. FBC CRP RP, blood c/s
sputum studies
evaluate specifically for:
infection
cancer- bronchoscopy + biopsy, CT staging, bone scan, lung function tests
infarction
causes of an unresolved pneumonia?
foreign body
tumour
abscess
inappropriate antibiotics, resistant organism
bronchopulmonary sequestration: rare, congenital. non-functioning lung tissue with anomalous arterial supply with no connection to the bronchopulmonary tree
what are the extrapulmonary manifestations of mycoplasma?
CNS- meningitis, encephalitis
CVS- pericarditis, myocarditis
hepatitis, GN
DIC, AIHA
Erythema multiforme, Steven-Johnson syndrome
Arthralgia, arthritis
complications of a pneumonia?
local:
abscess
empyema
respiratory failure
sepsis:
septic shock
ARDS
Multi organ failure
DIC
what are the pulmonary eosinophilic disorders?
defined as radiographic infiltrates with hypereosinophilia (>1.5 x 10^9 L)
- Churg Strauss (eosinophilic granulomatosis with polyangiitis): asthma with vasculitis and hypereosinophilia
- tropical pulmonary eosinophilia: high anti-filarial antibody
- chronic pulmonary eosinophilia: cough, progressive sob, weight loss with diffuse peripheral pulmonary infiltrates (see CXR)
management of pneumonia
depending on type:
community, hospital acquired
risk stratify: CURB-65 score
ABC approach
- may require non invasive or invasive ventilatory support in event of respiratory failure
- antibiotics
CURB 65 score?
helps to risk stratify patients with pneumonia
- confusion
- urea >7mmol/L
- RR >30
- BP< 90/60
- Age 65 and above
0 to 1: low risk of death, can treat in community
2: increased risk of death. short hospitalization or supervised home treatment
3 and above; high risk of death, urgent hospitalization
antibiotics for community acquired pneumonia?
generally penicillins or macrolides;
fluoroquinolones if intolerant e.g. levofloxacin
how to assess clinical probablity of PE
evaluate patients for:
- SOB, tachypnoea, chest pain, haemoptysis
- absence of an alternative explanation (A)
- presence of a major risk factor (B)
if A+B= high probability
only A or B= intermediate probability
none present= low probability
when to use d dimer in the workup of PE?
to use only if low or intermediate probability
high specificity= if negative, no need to do imaging
not to order if high probability-> should image immediately
imaging options for PE
CTPA
VQ scan: need to have facilities available
- cxr normal
- no cardiopulmonary disorder
US DVT: to confirm if VTE present
management of massive PE? ie BP compromised or cardiopulmonary collapse
thrombolysis with alteplase
thrombus fragmentation and IVC filters if expertise present and available
management of non massive PE?
no thrombolysis
use of heparin before imaging in high or intermediate clinical probability
- LMWH 1st choice
- unfractionated heparin if massive PE, first dose bolus, acute reversal desired
if PE confirmed:
anticoagulation usually for 3 - 6 months
management of PE in pregnancy
LMWH during pregnancy
unfractionated heparin when approaching delivery, to stop 4-6h prior delivery
oral anticoagulation commences after delivery and continued for 6 weeks or 3 months after PE whichever is longer
management of PE in cancer patients
duration unknown, may be indefinite while cancer persists
- higher risk of thombosis and bleeding
if recurrent thrombosis: can aim INR 3-3.5, LMWH + anticoagulation or IVC filter
how to diagnose COPD?
- clinical: > 35 years, smoking, wheeze, SOB, cough with sputum, winter bronchitis
- airflow obstruction: FEV1/FVC <70% and FEV1 < 80%
- exclude differential diagnoses: asthma, cancer, bronchiectasis, ILD
severity of airflow obstruction?
Mild FEV1 50-80%
Moderate 30-50%
Severe < 30%
features suggesting asthma on lung function test
> 400ml improvement with bronchodilator therapy or PO pred 30mg OM for 2/52 or variation in PEFR >20%
how do you grade the severity of dyspnea?
MRC scale
1- SOB on strenuous exercise
2- on hurrying or up hill
3- walks slower than contemporaries and stops for breaths
4- stops for breath after walking 100m
5- SOB on ADLs
ix of acute COPD exacerbation?
fbc (anaemia, polycythaemia), inflammatory markers
ABG
blood c/s
CXR
ECG
management of COPD?
non-pharm:
- education: stop smoking
- regular follow up
- vaccinations: pneumococcal, influenza
- PTOT pulmonary rehab, home adaptations
- MSW, specialist nurse for assessment of inhaler technique
pharmacological:
- Bronchodilators: LABA + LAMA +/- ICS
- theophylline
- +/- steroids
- mucolytics: acetylcysteine
manage complications of hypoxaemia, cor pulmonale, polycythaemia
surgery may be indicated
management of acute exacerbation of COPD?
ABC approach
may require non invasive or invasive ventilation if respiratory failure
-> BIPAP if hypercapnoeic and pH 7.25-7.35
- bronchodilators: salbutamol nebs
- steroids: PO pred/ IV hydrocortisone
- antibiotics if infective exacerbation
- oxygen therapy
indications for long term oxygen therapy for COPD
PaO2 < 55 mmHg
or
PaO2 < 60 mmHg + presence of:
- pulmonary hypertension
- polycythaemia
- cor pulmonale
- nocturnal hypoxaemia
For at least 15h/day if not 20 hours
management of polycythaemia 2’ copd
if Hct > 55%, may consider venesection
management of cor pulmonale 2’ COPD
diuretics
indications for surgical management in COPD?
bullectomy:
- for single large bulla, FEV1 < 50%
lung volume reduction surgery: upper lobe bullous involvement
- FEV1 > 20%
- TLCO > 20%
- pO2 < 45
transplant
when would you order alpha 1 antitrypsin levels in COPD patient
COPD +
- young
- family history
- no smoking history
not recommended for AAT replacement if positive for AAT deficiency, treat the COPD
COPD + air travel?
higher risk of hypoxaemia -> may require supplemental O2
pressurised at 8000 ft - higher risk pneumothorax
assess with: spirometry,
if SpO2< 95% on room air, hypoxic challenge test, 50m walk test
bring inhalers in hand luggage
inform the airline
what are the indications for a lobectomy or pneumonectomy?
- malignancy: mitotic lesion
- lung abscess
- localised bronchiectasis or its complications
- mycetoma, ABPA
- TB treatment (treatment modality for pTB in the past)
- Lung volume reduction surgery for COPD
- Trauma
indications for lobectomy and splenectomy?
TB
sarcoidosis
contraindications to a lobectomy/ pneumonectomy in a lung cancer patient?
resectability:
- T4 (mediastinal structures), N3 (contralateral mediastinal or hilar or ipsilateral supraclavicular LNs or scalene) or M1
- tumour within 2cm of carina (potentially curable by radiotherapy)
- bilateral endobronchial tumour (potentially curable by radiotherapy)
physiologic staging:
- severe pulmonary hypertension
- CO2 retention
- FEV1 < 1L
- Transfer factor < 40%
- concomitant disease that would shorten life expectancy
- recent MI in the past 3 months
- borderline function with cardiopulmonary exercise testing with a maximal oxygen consumption < 15ml/kg/min
indications for lung volume reduction surgery in COPD patients?
- emphysema
- predominantly upper lobes
- no or mild pulmonary hypertension (PASP<45 mmhg)
- no concomitant disabling disease
- FEV1 > 20% (but advanced COPD so should be < 45%), DLCO> 20%
others
- severe dyspnoea despite optimal medical therapy and maximal pulmonary rehabilitation
- age < 75 years
- smoking cessation > 6 months
likely underlying cause of a bilateral lung transplant in a young patient?
cystic fibrosis
alpha 1 antitrypsin deficiency
primary pulmonary hypertension
eisenmenger (Heart-lung transplant)
likely underlying cause of a bilateral lung transplant in an older patient?
COPD
idiopathic pulmonary fibrosis
bronchiectasis (always bilateral)
what are the indications for a lung transplant?
cardiopulmonary:
- primary pulmonary hypertension
- eisenmenger’s (heart-lung transplant)
chronic lung conditions:
- restrictive lung conditions: ILD
- obstructive: COPD, Alpha 1 antitrypsin deficiency
- suppurative: bronchiectasis, cystic fibrosis
- sarcoidosis
what are the contraindications for lung transplant?
disease specific guidelines
include
- age
- comorbidities: absence of concomitant disease that shortens life expectancy
- contraindications to surgery/ GA (recent MI)
- smoking, alcoholic, poor social support
what are the complications of a lung transplant?
- graft dysfunction (reperfusion oedema in the first week)
- airway complications: dehiscence, stensosis or bronchomalacia
- rejection: acute/ chronic
- Infection: CMV, aspergillus, bacterial (pseudomonas)
what to mention in examination of patient with a lung transplant?
- diagnosis
- likely underlying cause for the lung transplant
- complications of pulmonary hypertension, cor pulmonale, polycythaemia
- features of treatment side effects: e.g. steroid/ cyclosporin toxicity
acute vs chronic rejection in lung transplant patients?
acute:
lymphocytic inflammation
-> adjust steroid and immune suppression
chronic:
alloimmune inflammatory and non-alloimmune fibroproliferative, leads to bronchiolitis obliterans syndrome
management of lung tranplant
MDT approach, requires regular follow up, transplant coordinator
3 drug maintenance:
- calcineurin inhibitor (tacrolimus, ciclosporin)
- purine synthesis antagonist (MMF, azathioprine)
- steroid
CMV and PCP prophylaxis
what to mention in examination of patient with lobectomy/pneumonectomy
mention signs that may suggest underlying cause of lobectomy
what complications to examine for in respiratory examination?
pulmonary hypertension
cor pulmonale
polycythaemia
any respiratory distress/ failure (cyanosis)
what examination signs to look for in a patient with lung collapse tro malignancy
- any cachexia
- cervical lymph nodes
- signs of SVCO
- clubbing +/- HPOA
- horner’s syndrome
